靜脈血栓栓塞課件

靜脈血栓栓塞危重患者的VTE高危因素和發(fā)病率危重患者的VTE預防指南和評估ICU內的VTE預防方法幾個肺栓塞病例

Covidien|15January2024|Confidential3|靜脈血栓栓塞癥(VTE)包括深靜脈血栓(DVT)和肺栓塞(PE)。

DefinitionofVenousThromboembolism(VTE)

靜脈血栓栓塞的定義PulmonaryEmbolism1Circulation1996;93:2212;2NEnglJMed2004;350:22573Lancet1997;349:759;4JGenInternMed2000;26:425FatalPEAsymptomaticPESymptomaticDVTPulmonaryEmbolism4outof5patientswillnothaveanysymptomsofthrombosisAsymptomaticDVT20%80%80%ASYMPTOMATICS11050100300-1000Confidential,?TycoCorporation

Covidien|15/01/2024|Confidential5|解決DVT的后果靜脈血栓栓塞--

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation6|血流淤滯血管壁損傷凝血功能改變?yōu)槭裁磿纬蒁VT？當沒有任何預防措施時，DVT在某些專科中的發(fā)生率高于50％但是，僅有25％的DVT患者會表現(xiàn)出病癥O’Mearaetal.ProphylaxisforVenousThromboembolisminTotalHipArthroplasty.ORTHOPEDICS.深靜脈血栓流行病學〔外科各專業(yè)〕ICU入住前存在的高危因素ICU期間獲得的高危因素近期手術中心靜脈導管創(chuàng)傷、燒傷膿毒癥惡性腫瘤和治療因素藥物鎮(zhèn)靜、麻醉膿毒癥機械通氣制動/臥床、中風、脊髓損傷肌松治療高齡藥物治療心臟/呼吸衰竭VTE病史懷孕/產后雌性激素高臨床路徑推薦RiskfactorsforVTEActivecancerorcancertreatmentAgeover60yearsCriticalcareadmissionDehydrationKnownthrombophiliasObesity(bodymassindex[BMI]over30kg/m2)Oneormoresignificantmedicalcomorbidities(forexample:heartdisease;metabolic,endocrineorrespiratorypathologies;acuteinfectiousdiseases;inflammatoryconditions)Personalhistoryorfirst-degreerelativewithahistoryofVTEUseofhormonereplacementtherapyUseofoestrogen-containingcontraceptivetherapyVaricoseveinswithphlebitisForwomenwhoarepregnantorhavegivenbirthwithintheprevious6weeksRegardmedicalpatientsasbeingatincreasedriskofVTEifthey:havehadorareexpectedtohavesignificantlyreducedmobilityfor3daysormoreorareexpectedtohaveongoingreducedmobilityrelativetotheirnormalstateandhaveoneormoreoftheriskfactorsRegardsurgicalpatientsandpatientswithtraumaasbeingatincreasedriskofVTEiftheymeetoneofthefollowingcriteria:surgicalprocedurewithatotalanaestheticandsurgicaltimeofmorethan90minutes,or60minutesifthesurgeryinvolvesthepelvisorlowerlimbacutesurgicaladmissionwithinflammatoryorintra-abdominalconditionexpectedsignificantreductioninmobilityoneormoreoftheriskfactorsRiskfactorsforbleedingActivebleedingAcquiredbleedingdisorders(suchasacuteliverfailure)Concurrentuseofanticoagulantsknowntoincreasetheriskofbleeding(suchaswarfarinwithinternationalnormalisedratio[INR]higherthan2)Lumbarpuncture/epidural/spinalanaesthesiaexpectedwithinthenext12hoursLumbarpuncture/epidural/spinalanaesthesiawithintheprevious4hoursAcutestrokeThrombocytopenia(plateletslessthan75x109/l)Uncontrolledsystolichypertension(230/120mmHgorhigher)Untreatedinheritedbleedingdisorders(suchashaemophiliaandvonWillebrand'sdisease)PharmacologicalVTEprophylaxisForexample:Generalmedicalpatientsfondaparinuxsodiumlowmolecularweightheparin(LMWH)unfractionatedheparin(UFH)(forpatientswithrenalfailure).StartpharmacologicalVTEprophylaxisassoonaspossibleafterriskassessmenthasbeencompleted.ContinueuntilthepatientisnolongeratincreasedriskofVTEPatientswithstrokePatientswithcancerPatientswithcentralvenouscathetersPatientsinpalliativecareAllsurgeryCardiacsurgeryGastrointestinal,gynaecological,thoracicandurological物理預防在ICU的優(yōu)勢：ICU患者剛入院時大多具有消化道應激性潰瘍出血風險局部重癥患者有凝血功能障礙、腎功能障礙ICU患者本身情況復雜，用藥難以掌握,出血并發(fā)癥物理預防：ICU患者不可或缺19|靜脈瓣后去除SCD壓力系統(tǒng)提供最正確連續(xù)梯度壓力模式使股靜脈血流速度到達最大“理想的壓力模式為踝部35mmHg，小腿30mmHg，大腿20mmHg。〞“然而，由于廣泛存在的個體差異，這個壓力可以稍微增加〔例如45，40，30mmHg〕。〞

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation22|Nicolaidesetal.IntermittentSequentialPneumaticCompressionoftheLegsinthePreventionofVenousStasisandPostoperativeDeepVenousThrombosis,Surgery1980:87:69-76大腿小腿踝部壓力mmHgSCD壓力系統(tǒng)在股靜脈血液去除方面，速度明顯優(yōu)于小腿、單一壓力系統(tǒng).“SCD可以在很短的時間內清空靜脈瓣后淤滯的血液，而如果只對小腿施壓,相應的染色物質會停留長時間。〞〔小腿、單一壓力系統(tǒng)〕Confidential,?TycoCorporation

Covidien|15/01/2024|ConfidentialMittlemanetal.EffectivenessofLegCompressioninPreventingVenousStasis.TheAmericanJournalofSurgery1982;144:611-613

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation25|靜脈再充盈檢測

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation26|血液移動總量相同的情況在靜脈曲張的病人中，仰臥位增加71.9%，半臥位增加77.9%，坐姿時增加55.7%。〞Kakkosetal.Improvedhemodynamiceffectivenessandassociatedclinicalcorrelationsofanewintermittentpneumaticcomporessionsysteminpatientswithchronicvenousinsufficiency.JournalofVascularSurgery,Nov2001;Vol34,No.5,915-922將腿部血液清除達到最大值

主機連接管腿套/足套〔45mmHg,40mmHg,30mmHg〕(130mmHg)

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation32|J.CapriniMD.

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation33|T.E.D.AntiembolismStockingT.E.D.抗血栓壓力帶OtherAntiembolismStocking其它抗血栓壓力帶圓周鑲嵌編織法單向水平伸展確保抗血栓壓力帶的固定圓周編織提供單向伸展確保壓力分布正確定位垂直伸展使尼龍襪滑落UsingtheKendallTEDstockingswhichapplythecorrectpressureprofile,Holford(B.M.J.1976,2969-970)showedthatTEDstockingsreducedtheincidenceofdeepveinthrombosisinsurgicalpatientsfrom49%to23%andconcluded〞…improperdesign,constructionorfitcanbedangerous.〞垂直伸展使尼龍襪滑落7位半臥位自愿者，5個帶水壓計的可充氣套觀察血流速度確定理想的壓力分布18，14，8，10，8mmHg相對與基線，平均股靜脈血流速度增加138.4%

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation34|項目實驗組VS對比組結果結論1單物理預防VS單藥物預防無顯著差異物理預防和藥物預防一樣有效；但物理預防的并發(fā)癥更低2聯(lián)合預防VS藥物預防有顯著差異物理預防會使藥物預防更加有效3單物理預防VS聯(lián)合預防無顯著差異只使用物理預防足以有效預防DVT100+文獻證明SCD和TED的有效性

Covidien|15/01/2024|ConfidentialConfidential,?TycoCorporation36|靜脈血栓物理預防全方位解決方案AVI動靜脈脈沖系統(tǒng)SCD氣動歇式壓力裝置TED抗血栓壓力帶Case1：luckypatient，luckydoctorFemale，63yearsRecurrentsyncopeSpO260%~70%HypotensionECG：RBBBD-Dimer：2.386ug/mlCTA：肺動脈主干及雙肺動脈多發(fā)性栓塞rt-PA50mgDay-2:ECGnormal;有嘔吐表現(xiàn)CT小腦半球少量出血保守治愈

Case2：Bravedoctor第一次尿激酶溶栓150萬u一次VD，復查肺CTA如上圖，機械通氣氧合改善不滿意，未能脫機尿激酶二次溶栓4400u/Kg/h